Sunday 1 June 2014

Polish health cares long & winding road

It’s 4 weeks since I arrived in Krakow, Poland, on a 5-week field trip that represents the culmination of year 1 on the MSc Global Health programme.

Having been offered the opportunity to travel to either Tanzania or to Poland, I elected to come here to Krakow. The decision, in hindsight, wasn’t that difficult. In 2010/11 I spent some time working in Gambia and Kenya, I loved living both and am sure I will return at some point in the near future.  So there is perhaps a sense of irony - with Poland being less than 2 hours flight from Copenhagen – that I felt this may be one of my only opportunities to come and explore and work in a Central European country.

During the 5 weeks I’m based at Jagiellonian University, one of the oldest Universities in Europe with a rich and proud heritage, I was even fortunate enough to be here for their 650th anniversary. My main academic interest on arriving here was to delve into the world of a post communist health care system and discover the journey that Polish health care has been on over the past 23 years.

Collegium Novum Kraków

Brief history of Polish health care


Up until the late 1980s the polish health care system was largely based on the Semashko model, a heavily centralised system driven by the value ‘free health care for all’. While in principle it’s difficult for anybody to argue against that value, the system during the communist era was vastly underfunded with under the table payments common place for those wishing to access services. At this time, emphasis was placed on in-patient hospital care, little attention was paid to primary or secondary prevention, which further compounded the issues of under funding.  A further issue with the system was the vertical nature of programmes, with limited integration of services. For example children’s, adults and women’s health were organised within separate clinics, and co-morbidities were often not treated in conjunction.

With the fall of communism the Polish health care system underwent major transformation and restructuring. Service delivery was largely decentralised, with the administration of services moving from a national level to regional levels. The financing mechanism until around 1999 was largely the central budget, while after this date mandatory insurance contribution linked to the labour market took over. These contributions currently stand at 9%, however, they were originally intended to reach 12%, and thus there is clearly a large gap in the intended and actual income. At present there is only one administrator of funds, the National Health Fund (NHF) that collates contributions from all 16 regions (voivodeships) and then reallocates this back to regional NHF offices. There is are currently political murmurings about the need to decentralise the NHF allowing more autonomy at the regional level, Which could result in a system that looks similar to the clinical commission groups used in the NHS in England. Although at present it seems like this is some way off.

Moving forward; challenges and opportunities


A number of key things have stuck me during my time in Poland.

We haven’t ended a single lecture or visit without the issue of waiting times being mentioned in some context. It seems like this is an issue that cut across the whole of the health care sector. The government has been talking about cutting waiting times, particularly for oncology. In March of this year the Minister of Health outlined some initial ideas, such as cancelling limits on the number of oncological procedures and the introduction of a cap on the time from a patient visiting their primary health care physician to beginning treatment, this is currently proposed at 9-weeks. However, the real dilemma is that no additional funds have been identified for such activities. Which begs the question; where is the money coming from? The simple (and most likely) answer seems to be, other clinical departments budgets. Perhaps there is a suggestion that these reforms will bring efficient savings that can cover the additional costs. Undoubtedly there are efficiency saving to be made across the board, but this would likely take major restructuring, and of course time. The current worry is that if oncology becomes the key focus of the Polish government – and a flagship for the health systems success – will this have negative consequences for other departments?

The second thing to make me sit up and think was a visit to the Agency for Health Technology Assessment in Poland (AHTAPol). The agency was only launched in 2005, and now plays a critical role in the health system of Poland. One of the main responsibilities is to make informed recommendations to the Ministry of Health on what pharmaceuticals should be placed in the ‘guaranteed basket’ of services.  When services are included in this basket patients should have free point of access care which the service provider can then have reimbursed from the NHF.  It wasn’t necessarily the agencies current role or performance that got me thinking, but more the question; who was doing this before? As far as could understand the simple answer was, nobody.  With pharmaceuticals such an expensive element of any health acre system, having a regulatory body that can decide what should be provided based on cost to benefit, in an impartial, equitable and safe manner is essential.   The role of agencies such as AHTAPol will be essential in the coming years as the Polish health care system looks to control costs while improving access and quality of services.  Visiting the AHTAPol made me realise that certain core elements of the current health care system are still relatively nascent, while it also gave me a sense of positivity for the future with things are moving in the right direction.

Final remarks


The factors I have mentioned here may in fact not be particularly novel, the issues of financing and equity in access and quality of care can be applied to all heath systems around the globe.  As a health care system that has undergone some major transformation over the past decades the Polish system is one that perhaps needs some level of stability. Political commitment to reducing waiting times is commendable, but only if it results in concrete policies that ensure equitable utilisation, access and quality of care across the board, which will inevitably need to be accompanied by the appropriate funding mechanisms.

It has been an interesting and enlightening time in Poland. Krakow has been a great city to spend time in and one that I can recommend to all!

Hope you enjoyed the read
Henry.


Reference:

The background for this piece came from lectures provided at Jagiellonian University, Krakow and from visits to agencies and institutions during the field trip. A general reference below can give more insights into the Polish health system for those interested.

Paulina Pieprzyk. The polish health care system’s endless journey to

Perfection – a never ending story ‘‘Social Transformations in Contemporary Society’’, 2013 (1) ISSN 2345-0126 (online)

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